When Seniors Need House Calls

The Gilchrist Elder Medical Care at Home program was created to meet the needs of seriously ill seniors who are no longer able to make trips to the doctor. With Elder Medical Care, these individuals—who often lack caregiver support and have challenges with activities of daily living—can receive the care they need in the comfort of their own homes.

Starting as a small pilot program with one nurse practitioner in November 2014, Elder Medical Care has rapidly grown to an interdisciplinary model that now delivers in-home medical care and psycho-social support to over 296 patients and families each year throughout the region. These individuals would otherwise have few options for care other than the emergency room.

The Elder Medical Care program provides comprehensive, coordinated care across settings. When one of our patients unexpectedly goes to the hospital, the Gilchrist team is automatically notified, allowing a clinician to meet the patient and ensure that they are informed about their options for care and their choices are honored.

As a patient’s care needs change, team members ensure seamless transitions from one Gilchrist or community program to another and help identify additional resources and services that enable the patient to remain at home as long as desired. If an individual’s illness progresses to the point of needing hospice, they can quickly transfer to Gilchrist Hospice Care. And if an individual no longer needs hospice care, they can easily transfer back to Elder Medical Care, ensuring there are no gaps in service.

Gilchrist is committed to ensuring all providers involve patients and families in shared decision-making. Decision-making preferences are established up front and include a discussion of identifying a health care decision-maker (HCDM) and Medical Orders for Life-Sustaining Treatment (MOLST). Nursing and social work staff are specifically trained on how to conduct these discussions and assist the patient and family in making informed medical choices.

Gilchrist Elder Medical Care at Home is part of the Baltimore House Calls Collaboration that includes MedStar House Calls Program and JHome, the Johns Hopkins House Calls program, and other house call providers through the region. This collaboration provides a forum for sharing best practices and community resources and exploring how each might be using innovations, such as telehealth monitoring.